This five-year proposal seeks to develop, implement and evaluate a computer-based clinical decision support system that provides access to problem-based knowledge to physician and nurse clinicians for the purpose of learning and consultation. Essential tasks will be 1) iterative development of interfaces incorporating easy-to-use contextual and graphical indexing techniques; 2) development of database structuring techniques and authoring tools to create problem-focused clinical knowledge bases incorporating "chunks" of expert knowledge, organized according to the kinds of questions clinicians frequently ask. The technology will be applied to three clinically important topic areas where expert consultants are frequently used, and where expert knowledge is believed to make a difference in quality of decisions made: 1) troubleshooting and management of patients with a pulmonary artery catheter; 2) prevention and management of skin breakdown; and 3) management of patients on a ventilator. The project will proceed in overlapping phases, with development, testing, refinement and implementation of one topic area at a time. The technology will be implemented on a 41-bed step-down cardiac surgical intensive care unit, with high incidence of patients at risk for skin breakdown, and frequent occurrence of ventilated patients. Evaluation will consist of four protocols: 1) Evaluate the instructional and consultative adequacy of the technology. 2) Evaluate the effectiveness of the technology for imparting knowledge and decision-making skills to clinician users. 3) Evaluate clinical outcomes (i.e., incidence and management of decubiti) on the experimental unit prior to and after implementation of the technology for the SKIN topic. 4) Evaluate cost-effectiveness of use of this technology for imparting clinical knowledge to users, and for prevention of adverse clinical outcomes related to skin care.